Recent News from Dr Ivan Kohl

The Association of Private Cardiologists in the Czech Republic met several times in 2007 and consulted our colleagues of the Council for Cardiology Practice on the following matters:

Are there standards in other European countries which state precisely which procedures can by performed by the private cardiologist when receiving patients with specific cardiac diagnoses?

Do other European countries generally follow national guidelines? Or do they use ESC guidelines which were endorsed and translated into the local language?

Do colleagues in private practice cardiology have the possibility to influence the elaboration of guidelines in their countries based on their specific experience?

Do colleagues have regulations in their countries to limit the quantity of work, the quantity of drugs prescribed, and the quantity of X-rays or laboratory examinations?

Response from Germany, France, Spain and Norway

Procedures

France has no specific guidelines on procedures to be performed by private cardiologists.

Spain: private cardiologists work in out-patient clinics and in private hospitals. All procedures, excepting heart transplants, could be done in private practice.

Germany: All procedures, except surgical procedures, are performed by hospital cardiologists. The quality of the procedure and clinical standards are controlled and, if up to standard, the procedure is reimbursed.

Norway: We have no national guidelines concerning the relation between cardiologists in and out of hospital.

Guidelines France has both national guidelines guidelines and ESC guidelines endorsed by the national society of cardiology and translated into French.

Spain follows the ESC Guidelines endorsed by the Spanish Sociey of Cardiology and translated into Spanish.

Germany's "Klinische Kommission" is responsible for national guidelines. Cardiologists of all segments (university, non-university departements, out-hospital cardiologists and specialists of other groups are involved to adapt international guidelines to national standards. Practitioners use national guidelines.

Norway: The ESC guidelines are evaluated by a national guideline committee. Some are endorsed, other changed slightly for instance the latest with respect to lipid and risk.

Do colleagues influence guidelines?

France: Yes. National guidelines are partly elaborated with private practice cardiologists. The Council for Cardiology Practice contributes to the elaboration of ESC Guidelines.

Spain: Yes. We are on the Guidelines Comittee of the ESC. Not only clinics, haemodynamists and echocardiographists have been involved as well.

Germany: Yes. Two members of the BNK (German National Association of Private Practice Cardiologists) are elected to take part in the Klinische Kommission. This is in accordance with the statutes of the German Society of Cardiology.

Does your country have regulations to limit quantities of work, prescriptions and examinations?

France: Yes, a fixed global sum is dedicated to private physicians per year. The number of X- ray and laboratory exams is limited?

Spain: We have no limitation but we are accountable for our decisions which are followed by the private insurance companies. We must also prescribe generic drugs as the first choice because our National Health System is paying for them. We can only use other kinds of drugs if the patient presents intolerance or there is no generic substance.

Germany: We follow budgets which define the quantity of work performed. We are not reimbursed if we exceed the budget allowance for X-ray, echocardiography etc. If your prescriptions exceed more than 25% defined in the budget of your reference group (usually the non-hospital cardiologists of your region) you are accountable and could even be asked to pay for the drug prescribed.

Norway: In Norway, the concession to work as a private specialist outside hospital is strongly regulated. Currently there are about 26 concessions country–wide. Without concession one will not receive the annual fixed payment (€110 000) and cannot send bills to the National Health System. However, a private cardiologist is free to set up a totally private practice where the patient pays for everything, (i.e. €300 for an examination with echo and X-ECG), but there are few patients who are willing to pay for this. Compared to private internists, cardiologists can charge the National Health Care system for echocardiography, in other respects (ECG, Exercise ECG etc.) there are no difference between a private internist and a private cardiologist. General practitioners are not allowed to charge for exercise ECG and Holter. A private cardiologist is not allowed to set up facilities for coronary angiography/PCI. This is also strongly regulated at national level; even local hospitals cannot do this as they please, as the re-imbursement is regulated nationally. To set up facilities for X-Ray/multi-slice CT one has also to have concession as an X-Ray clinic, which is hard to get, so in practice only established laboratories can do this. Otherwise, private cardiologists can act according to their competence. For instance one can have a nurse-led heart failure and rhythm out-patient clinic, do tilt-testing and EECP treatment. Some procedures - like DC conversion for AFIB, contrast-echo, are not reimbursed and thus not done privately. There is no upper limit on reimbursement. There is a normative number of annual consultations (1800), if 20% below this without good reason, one might lose the concessions as a private cardiologist. Drug prescription is free, but there are national guidelines on preferred treatment if one makes out a prescription on a National Health Care prescription form ( the patients then pay a maximun of €40) For instance, hypercholesterolemia should initially be treated with simvastatin, if not the reason should be written in the patient’s records. Uncomplicated hypertension should be treated initially with tiazides (strongly disliked by most cardiologists), if not, the reason should be stated in the records.

Introduction of a financial contribution from patients

1 euro per consultation with GPs and out-hospital specialists 3 euros when admitted to an emergency departement 2 euros per day spent in hospital.

The Czech government presented the introduction of the regulatory fee as a first step in the reform of the Health Care system in the Czech Republic.

Annual Meetings of the Association of Private Cardiologists in the Czech Republic

Heart Failure was the theme of the 2007 Autumnal Meeting of the Association of Private Cardiologists in the Czech Republic. Discussions focused on:

how to manage Heart Failure in daily cardiology practice

the need to appreciate how patients with chronic heart failure can be better profiled to ensure tailored treatment

which of the available new methods can be used in the specific conditions of out- hospital cardiologists including financial limits assigned by the Ministry of Health and insurance companies.

The Association of Private Cardiologists also meets during the annual meeting of the Czech Society of Cardiology.

General background

In the Czech Republic, both state and private medical facilities exist. Almost all facilities have concluded contracts for the provision and payment of health care with health insurers and provide health care to patients, insured at the relevant health insurers, without direct payment. Patients can visit specialists in the Czech Republic without a recommendation from their primary care doctor. According to statistics there are 40,800 physicians in the Czech Republic. 7,500 of them are specialists who work as private, or improved contract, medical care providers. They have a contract for out-patient care with the main insurance companies. The Czech Society of Cardiology has currently (December 2007) 526 certificated cardiologists on file. 182 of these certificated cardiologists provide their own private contract and practice. They are paid by insurance companies and there is no direct payment from insured patients.

Education of new cardiologists is based on the "Recommendations of the European Board for the Speciality of Cardiology (EBSC) for education and training in basic cardiology in Europe", and their education level should be the same as in the other countries of European Union.

The Association of Private Cardiologists in the Czech Republic

The Association of Private Cardiologists in the Czech Republic was established as a civil association in 1997 and has 80 members today. The leading members of the association (chairman, the co-ordinating committee of 7 members and the auditing committee of 3 members) are voted for a period of two years by the General Assembly which takes place every year in Prague.

Leading members of the association

Dr. Hana Skalicka is the current Chairperson. Dr. Zorjan Jojko, on the coordinating committee, is also a member of the board of the Czech Medical Chamber where he deals with the problems of private specialists. Within the association Dr. Lubos Berka is also concerned with the economic problems of the private cardiologists. The association is active in two main fields. The first is medical science and the second concerns activities as private medical care providers. Nearly all the members are also members of Working Groups of the Czech Society of Cardiology and participate every year in the organisation of the annual congress of the society. They select up to date subjects and themes and, in the special section of the congress, have their own lectures and invited specialists. Cardiology lectures are also presented during the annual assembly of the association in Prague.

Private medical care practice

The association is part of the Association of Contract Physicians of the Czech Republic (now called the Association of Ambulatory Specialists). Delegates participate regularly in the following activities:

conciliation procedure between public health insurance and medical care providers

medical operation points attribution (for reimbursement procedures)

medical operations register

tariff lists for cardiology operations

advise on contracts between private physicians and insurance companies